Download Cardiac Care for Older Adults: Time for a New Paradigm

Cardiac Care for Older Adults: Time for a New Paradigm
Daniel E. Forman, MD1,2
Michael W. Rich, MD3
Karen P. Alexander, MD4
Susan Zieman, MD5
Mathew S. Maurer, MD6
Samer S. Najjar, MD7
Joseph C. Cleveland, Jr., M.D.8
Harlan M. Krumholz, MD9
Nanette K. Wenger, MD10
1. Brigham and Women’s Hospital, Boston, MA.
2. New England GRECC, Boston VA Healthcare Center, Boston, MA
3. Washington University School of Medicine, St. Louis, MO
4. Duke University Medical Center, Durham NC
5. National Institute on Aging/National Institutes of Health, Bethesda, MD
6. Columbia University Medical Center, New York Presbyterian Hospital
7. MedStar Health Research Institute, Washington Hospital Center, Washington, DC
8. University of Colorado at Denver, Division of Cardiothoracic Surgery, Denver, CO
9. Yale University School of Medicine, New Haven, CT
10. Emory University School of Medicine, Atlanta, GA
Special thanks to William Hazzard, MD for his review, thoughtful comments, and strong
endorsement
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Introduction
Advanced age as a primary determinant of cardiovascular disease
Recent decades have witnessed striking growth in the number of older adults both in the
US and throughout much of the world largely due to improved public health, nutrition, and
medical care. Between 2000 and 2030, the proportion of the world's population age 65 and older
is expected to increase from 6.9% to 12% (1). In the US, the ‘old age’ demographic is
accelerating even more rapidly (from 12.9% to 20% between 2000 and 2030) as baby boomers
enter their senior years (2). Furthermore, by 2050, the subgroup of US seniors aged 85 years and
older is expected to triple. Ironically, aging also catalyzes fundamental changes that increase
susceptibility to cardiovascular disease (CVD) such that CVD is endemic in the burgeoning
senior population (3). Already, the prototypical US cardiology patient is an older adult and
management of cardiac issues is fundamentally linked to the frailties and multi-morbidities
associated with advanced age.
Cardiologists are frequently regarded as the logical healthcare leaders for the rising population
of older adults with CVD
While many assume that cardiologists are logical healthcare leaders for management of
CVD in seniors, the current CV armamentarium fails to integrate complexities or needs specific
to older patients. Conventional evidence-based standards of CV care were formulated using trial
data derived from younger study populations and/or elderly patients who were rigorously
screened to exclude common morbidities or frailties of old age (4). As a result, routine CV
management often overlooks health problems without a cardiac focus (e.g., cognitive decline,
functional limitations, pain, or multi-morbidities) even if they bear on how patients experience
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and process CV healthcare decisions (5). Primary care providers may even choose to avoid
cardiology consultation if they perceive that the cardiologist will recommend medications and
procedures that are discordant with the patient’s overall care priorities (6). Moreover, in some
areas of the U.S. third party payers are considering steps to impede referrals to cardiologists for
what are perceived to be invasive procedures that add little benefit to patient-centered care (7)
such as the common use of stents in stable CAD patients, an issue particularly germane to older
adults given the high age-related prevalence of CAD.
It is indisputable that the attributable risk of CV disease is highest in the senior
population (8,9,10). Therefore, CV caregivers have the greatest potential to favorably impact
mortality and morbidity by implementing preventive and interventional therapies in their oldest
patients. Yet, this potential is counterbalanced by increased iatrogenic risks as well as myriad
medical, social, and even economic concerns that can affect which issues a patient considers
his/her paramount concerns. To navigate amidst these cross-currents cardiologists require
additional proficiencies, i.e., insights and skills that require deliberate preparation and training.
The Institute of Medicine’s recent report on retooling for an aging America emphasizes
the need for fundamental reform in healthcare training and implementation to meet the needs of
the older population (11). “The nation needs to move quickly and efficiently,” the report
indicates, “to make certain that the health care workforce increases in size and has the proper
education and training to handle the needs of a new generation of older Americans.”
We propose that fundamental tenets of CV training and patient management can and
should be expanded to better address the complexities of all patients, including skills and insights
to better treat the large and growing population of older adults who now comprise the largest
subgroup of CV patients. Training should continue to emphasize state-of-the-art technological
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and medical expertise, but also their individual application, and ensure that all providers have the
skills needed to assess patient preferences, circumvent hazards of hospitalization, facilitate
successful transitions from one care setting to the other, engage in useful risk:benefit discussions,
and provide care collaboratively within a care team responsive to the needs of the oldest
patients. Such enhancements will lead to more individualized care, with better coordination
across multiple conditions.
Aging leads to changes in the nature of CV disease and its management
While chronology is relevant, the process of aging entails more than an accounting of
years lived (12). Relative differences in biology (e.g., telomere length, oxidative stress,
inflammation, genetic constitution) (13,14,15), lifelong health habits (e.g., nutrition, exercise,
dental care), cardiac risk factors (e.g., hypertension, cholesterol, tobacco, insulin resistance) (16),
co-morbidities (e.g., infection, COPD, renal disease, anemia, arthritis, depression, dementia,
vision and hearing deficits), psychology (e.g., interpersonal capacities, self-efficacy, coping
skills), social structure (e.g., class, community, access, spouse, family support), economic
resources (personal, governmental), and culture (religion, ethnicity, transcendent sense of
meaning and purpose) also impact the aging process. Therefore, a more meaningful way to
conceptualize “aging” is as a continuum of changes that mount over time, with pace and nature
of progression varying depending on each person’s circumstances.
Despite such individual variation, 75 years is often cited as the beginning of old age, in
part because it provides a convenient benchmark for research and clinical applications.
Likewise, 85 years is often used as a convenient threshold to classify very old age. These
designations presume that by 75 and 85 years respectively, most adults have sustained sufficient
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aging changes to exhibit clinically relevant differences in physiology and organ function and
reserves. Yet aging remains idiosyncratic, and each senior adult has a unique constellation of
age-related vulnerabilities and consequences.
High age-related incidence of CVD arises in part due to broader aging processes,
including accumulating morbidities, diminishing homeostasis, and prolonged injurious effects of
CV risk factors (3,17). Cardiac disease also stems from insidious age-related changes in CV
morphology and function. Vascular stiffening of the central vasculature is, for example, an
omnipresent aging phenomenon that usually starts by middle age and leads to progressive rise of
afterload stress, myocardial workload, and changes in diastolic perfusion that predispose to
functional decrements and ultimately to ischemia, heart failure, arrhythmia, and other CV
disorders (18,19,20). Heart failure with preserved ejection (HFPEF) becomes increasingly
common as the mounting aortic impedance of senescence is more likely to uncouple from
ventricular pumping performance (21). Parallel aging changes in myocytes, endothelial cells,
and pacemaker cells further increase vulnerability to coronary artery disease, valve disease, heart
failure, arrhythmia, peripheral artery disease, and cerebrovascular disease (20). The relative
progression of each of these aging effects varies among individuals, resulting in a diverse range
of CV clinical implications. For some seniors, CV aging is manifest only as functional
decrements (22), while others develop subclinical (23) or overt CVD (3,17,20,24). While overall
CVD increases appreciably with age, cardiologists face the challenge of tailoring prevention and
treatment priorities relative to each individual’s circumstances.
CVD is also usually more hazardous in older patients. It often erupts with multiple
simultaneous CVD processes (e.g., acute coronary syndrome, heart failure, and atrial fibrillation)
and in combination with non-cardiac pathologies (e.g., pneumonia, renal insufficiency, anemia,
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chronic lung disease, diabetes, stroke) (24). Such multisystem disease combinations are more
liable to overwhelm the diminished CV reserve capacity of aging, thus leading to adverse
outcomes. Medications often compound problems, as age-related changes in absorption and
metabolism alter the pharmacokinetics and pharmacodynamics of most drugs. As a result,
medication dosing and effects, both beneficial and adverse, often differ from those in younger
adults, and it cannot be assumed that the clinical utility of agents shown to be effective in
younger individuals necessarily applies to the elderly. Moreover, especially given the likelihood
of multiple cardiac and non-cardiac diseases occurring simultaneously among older CVD
patients, clinically significant drug-drug and drug-disease interactions are ubiquitous, adding to
management challenges (25).
Limitations of the current therapeutic paradigm
Despite the glaring pattern of age-related complexity and precarious onset and
progression of disease, the current paradigm of care for older CV patients is relatively
rudimentary, mostly an extrapolation from conventional evidence-based CV guidelines. Even
the recently revised NSTEMI guidelines which called for special considerations in care of older
populations, provided little in the way of concrete recommendations (26). Essentially,
cardiologists have begun to approach the margins of the issue, but have yet to deal with it
programmatically.
Evidence-based care becomes considerably less certain when analyzed through a lens that
exposes relevant aging dynamics. For example, while an impressive array of trial data suggests
utility of statins to reduce mortality for older adults (27,28), therapeutic ambiguity persists if the
statin constitutes the 8th pill in a complex regimen and/or if the patient has age-related renal
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insufficiency and/or nebulous muscle aches (29,30). Not only are the salutary effects of a multipill regimen for a frail elder unclear, but diminished access to care, costs, iatrogenesis in relation
to age, polypharmacology, and morbidity remain substantial concerns, with absent clarification
from the clinical trials on which treatment indications were based, i.e., trials which
systematically excluded older patients with such complexities (4). Furthermore, data pertaining
to adults aged 80 years and older remain generally absent and benchmark mortality endpoints are
often of less concern for seniors than quality of life issues (e.g., myalgias, polypharmacology,
and medication costs).
Part of the challenge is that many CV interventions effective in younger patients are more
likely to adversely affect older adults, especially those weakened or debilitated by age (31).
Contemporary proliferation of drug eluting stents and anti-platelet therapy, for example, is
counterbalanced by increased bleeding risks in older patients (32). Beta-blockers can limit
chronotropy and exercise performance. Nitrates can increase falls and syncope. Idiosyncratic
effects of age must be anticipated. Complexities are exacerbated by cognitive decline,
confusion, mood changes, and loss of appetite, especially in a context of common stresses of
hospitalizations, loss of independence, functional declines, polypharmacology, and sensory
impairments (vision, hearing, taste). Precise dosing of medications and monitoring are essential,
as is thorough assessment of composite life events which impact on CV health and care.
Advanced age and frailty also often confound conventional processes of care. Access to
caregivers is often more limited (hindering assessments and monitoring); vision, hearing and
cognitive limitations can complicate comprehension and compliance; arthritis impedes exercise
goals; financial constraints and altered taste may frustrate dietary recommendations; finances
may also prohibit use of vital ancillary services; even the ability to stand on a scale can become
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difficult for someone challenged by dizziness, stroke, or Parkinsonism. Therapy that merely
extrapolates from standards oriented to younger populations might be fundamentally unsuitable
for someone old and frail.
Not only do higher risk:benefit ratios exist among seniors for virtually all CV procedures
and interventions relative to the populations from which evidence-based standards were derived,
but even if/when study endpoints are reproduced in seniors, many patients may not perceive
them as benefits.
The manner and quality of death can also be affected by therapeutic choices in ways far
removed from their original therapeutic intent. An implanted cardioverter-defibrillator may, for
example, prevent sudden (painless) death, but this “benefit” inevitably increases the likelihood of
dying from congestive heart failure, myocardial infarction, cancer, or other non-cardiac causes
(33,34). Such consequences are often not anticipated and discussed prior to undertaking
therapeutic interventions.
Limitations of the current CV healthcare paradigm to care for seniors extend beyond
decisions made for an individual patient and relate to the healthcare industry. Over the last
decade, access to CV imaging, procedures, and devices have expanded for older adults. There
has, for example, been enormous investment in nuclear imaging on the premise of quality (35),
often usurping the role of traditional ECG exercise testing that still might have provided
sufficient data to address the underlying clinical questions (e.g., prognosis, exercise capacity, and
symptoms) without the added expense of imaging (36). These issues are now compounded by
growth of CT and other imaging options which tout clinical benefits, but for which outcomes
data are lacking. While concerns regarding over-reliance on imaging are not exclusive to older
patients, prevalence of CVD increases with age (such that application of imaging assessments
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also escalates) as does a common (but erroneous) assumption that older patients cannot exercise
sufficiently for clinically useful non-imaging assessments.
Improving care of the older cardiac patient
A new clinical paradigm
Given the fundamental heterogeneity of aging and its direct bearing on clinical
management, improved care for older CV patients is a priority (37). Considerable work lies
ahead to achieve what are still sometimes idealized goals that must be better delineated and then
promoted amid many contrasting and competing versions of healthcare priorities.
Improved CV management for seniors must start with capacity for comprehensive
assessment of each individual’s health as well as a multifaceted health context, with therapy then
personalized to each patient’s situation. Tools to gauge overall health and to link composite
health profiles to customized and achievable therapeutic goals are needed. Patients must be
engaged in the selection of the management choices bearing on their health, but the medical
system (and cardiologists in particular) must achieve processes, organization, and standards that
insure that seniors receive lucid, relevant information in a straightforward comprehensible
manner.
While longevity may remain the dominant priority for some older adults, the prospect of
excessive pain, hardship (including perceived burden on loved ones), limitation of independence,
and/or recurrent hospitalizations may limit appeal of life-prolonging therapies, particularly
amidst chronic disease and progressive debilitation. Just as cardiology has cultivated vast insight
and expertise oriented to extending longevity, it now is crucial to refine health goals oriented to a
spectrum of alternate endpoints, i.e., quality of life, functional capacity, reduced hospitalizations,
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and independence. The evidence-base foundation of CV medicine must expand to achieve
insights and rationales that support and guide these non-mortality objectives.
While in some cases, clarification of therapeutic objectives may be as simple as direct
patient inquiry, this process will often be confounded by affect, cognitive decline, social
pressures, and/or family dynamics, especially in situations involving advance directives or
healthcare proxies. Furthermore, given that aging is dynamic, therapeutic goals may fluctuate
relative to advancing age and circumstances. Interviewing techniques and assessment strategies
must be efficient, sensitive, and reliable for recurrent assessments for a wide range of
personalities and settings.
Risk stratification is a related dimension of assessment that is particularly important in
assessing eligibility of older adults for CV procedures (38,39,40). The goal is not to restrict
treatment, but to better select patients for therapy who are most likely to benefit. The decision to
undertake revascularization should be based not solely on results of imaging procedures and
anatomical criteria, but on aggregate patient circumstances. Coronary anatomy is relevant, but
so too are comorbid features (e.g., renal, pulmonary) that impact procedural success and
complications. Likewise, even technically successful revascularizations may culminate
suboptimally if cognitive, comorbid, and social limitations were not recognized and addressed
prior to undertaking the procedure. Beyond conventional parameters of coronary anatomy and
comorbidies, seminal work by Fried (41) highlights that many aspects of frailty also impact CV
outcomes; e.g., unintentional weight loss, weakness, self-reported exhaustion, slowness of gait
speed, low activity, and poor grip strength are important considerations. Assessments once seen
as “soft” or subjective (e.g., fatigue, weakness, gait speed) are now increasingly acknowledged
as providing important prognostic information. Such innovative assessments have been
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reinforced by tools to increase their reliably and objectivity (42,43,44,45), important refinements
to refute those who still see them as soft and inconsequential. Cognition (delirium risk) (46),
social support, and mood (depression) (47) must be considered in assessing risk. Concomitant
pharmacotherapy should also be taken into consideration; e.g., chronic need for warfarin
increases bleeding risk following PCI, and may affect the choice of anti-platelet therapy or the
type of stent to deploy (i.e. bare metal vs. drug-eluting stent) (48).
For patients prioritizing quality of life, function, independence and other clinical goals
over longevity benefits, therapeutic strategies must shift. While digoxin did not reduce mortality
in the DIG trial, more important may be its benefit in reducing heart failure symptoms and
related hospitalizations in older patients (49). Although milrinone for systolic HF may be
associated with increased mortality risk, its potential to increase function and quality of life may
seem worth that risk to an elderly patient (50). Even therapeutic bastions like beta-blockers may
seem less useful for frail heart failure patients whose vulnerability to chronotropic incompetence
(and potential need for a pacemaker with associated procedural risks and other adverse
outcomes) and functional decrement may outweigh their life-prolonging benefits.
Similarly, rationale for stents, devices, and surgery must be reconsidered in terms of their
value with respect to the personalized clinical goals of each patient. Whereas the utility of
revascularization to increase life expectancy may seem nebulous, its value may seem relatively
clearcut if improved function, quality of life, and independence are the primary therapeutic
objectives (51). Treatment pathways can be delineated in ways that help patients, families, and
allied caregivers understand which older patients are most likely to benefit. Likewise,
procedures can be refined and standardized to better facilitate these goals (e.g., type of stent,
hybrid procedures, and/or adjunctive therapy). The onus is on cardiologists to achieve
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technological and methodological advances to best assure excellent outcomes for seniors, and to
disseminate these refinements as priorities. Bivalirudin and fondaparinux may, for example, be
better anti-thrombin agents for older adults undergoing PCI (52,53,54). Sheath sizes, antiplatelet therapy, and other clinical processes may be better tailored to specific patient criteria.
Similar approaches to minimize age-related renal toxicity, delirium, and other morbidity are all
mandated.
Fundamental strategies of therapy may also change to better manage the risks and
limitations associated with age, and to achieve outcomes that are particularly valued. The recent
report of success with Transcutaneous Aortic Valve Implantation (TAVI) in patients ineligible
for traditional valve surgery provides an excellent example of how technological advances may
better facilitate successful patient-oriented outcomes (e.g., improved independence and quality of
life) for patients who would be unlikely to benefit from traditional therapeutic strategies (55).
Improving communications and transitions for older CVD patients
Improved communications are vital to all dimensions of care. Many older adults have
natural barriers to optimal communication due in part to diminished cognitive and memory
capacities, auditory and visual impairments, and limited social support, as well as the complexity
of their medical issues (i.e., it is simply hard for many to understand the concepts).
Communications are critical for patients to grasp complex concepts of aggregate health risk and
be able to make personalized healthcare choices. Given these typical obstacles, language and
learning tools can be refined and standardized to be more effective. Not only can doctors,
nurses, and other staff be better trained to communicate with older patients by adapting to
individual patient’s health literacy, education level, cognitive function, and culture, but hearing,
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vision, and learning props can be integrated at key junctures of care. Well-coordinated
information can also be provided to families, spouses, and others involved with a patient’s care,
being careful not to undermine the patient’s autonomy and right to make choices, but rather to
insure consistency, clarity, and a shared sense of information. Equally important, information
should be readily available to all caregivers involved in each patient’s care, i.e., primary care
physicians, hospitalists, other specialists, nurses, physical therapists, and nutritionists, with the
goals of consistency in information exchange and minimizing iatrogenesis. A related priority is
that cardiologists communicate effectively with their medical colleagues. Optimal CV care
demands a team approach to address the complexities of older patients. CV management must
be coordinated within the caregiving team; unambiguous and timely information flow and
documentation are essential (56).
Communications also relate to the ability of CV specialists to hear senior patients, i.e.,
not only as part of the process to determine personalized therapeutic goals, but as a means to
gauge the efficacy of therapy. Especially given that many non-mortality endpoints rely on
qualitative parameters, listening and hearing are elemental components to assess caregiving
quality and effectiveness (57).
Cardiac rehabilitation can be better utilized to reduce morbidity and mortality, improve
quality of life, increase functional capacity, reduce readmissions and reduce healthcare costs for
elderly patients (58). Cardiac rehabilitation specifically responds to challenges experienced by
most older CVD patients, i.e., multi-morbidities and complex medication regimens.
Unfortunately, access remains a substantial impediment and there has been little in the current
healthcare financial environment to ease this problem. While many older patients are not
referred because they are deemed too frail, these patients often achieve the greatest benefit.
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Improved transitions of care have also been demonstrated to confer significant value for
seniors (59,60,61). Certainly cardiac rehabilitation can help in the transition of cardiac patients
to home, but transitions also pertain to those entering the hospital, transferring between hospital
units, or returning to home after rehabilitation. Transitions are often particularly detrimental
among those with multi-morbidities and frailty, especially those with cognitive and sensory
(vision-hearing) limitations. Steps that reinforce communications, consistency in medications,
diminished confusion and agitation, and timely follow-up will best insure successful outcomes,
and also help relieve stress, improve quality of life, and increase long-term adherence.
Financial emancipation from the current paradigm of healthcare
While a comprehensive discussion of the implications of aging on healthcare finances is
beyond the scope of this manuscript, reimbursement for healthcare services must become better
aligned with, and more mindful of, age-related dynamics. Current reimbursement strategies
provide incentive for performance high tech diagnostic and therapeutic procedures and
disincentive for physicians to spend extra time discussing management options and patient
preferences with older patients Furthermore, low tech therapies, such as patient education,
smoking cessation, and cardiac rehabilitation are poorly compensated or not compensated at all,
despite their proven benefit in reducing CVD risk and/or improving outcomes. The fact that
cardiac rehabilitation enrollment falls to less that 12% of eligible elderly CVD patients is a
glaring example (58,62) of an under-utilized low-tech therapy that has been clearly associated
with both life-enhancing and life-prolonging benefits. Although an abundant literature speaks to
typical barriers, including limited physical access (many cannot drive), spousal responsibilities
(particularly women cannot participate due to caregiving obligations for their husbands), and
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finances (even the co-pay is prohibitive to many) (59), there has been little effort to overcome
these obstacles as an integral component of healthcare reform legislation. Other low tech options
that merit greater application include community and home-care exercise programs,
transportation services, spousal care services, and homecare providers (to help older patients
organize medications, shopping and cooking, and physician appointments and bills). Although
additional study is needed, all of these services would likely be greatly valued by many elderly
CVD patients, thereby improving quality of life. There is also significant potential for these
services to improve clinical outcomes, including hospitalization rates, and lower overall costs of
care.
Including family in the spectrum of care
In general, goals to improve CV care for seniors pertain not only to the older patient, but
to the family caregivers whose lives are commonly consumed with and/or mired by the patient’s
health issues. Cardiology has rarely addressed the extensive caregiver burdens that result from
complex CV medication regimens, CV-related functional impairments and dependencies,
procedures, and other aspects of CV care, despite awareness that associated morbidity and
mortality risks for caregivers are significant (63). Steps to personalize therapeutic goals,
enhance communications, and improve transitions will not only benefit patients, but family
caregivers as well.
End-of-life planning in the spectrum of care
End of life issues should also be better incorporated into routine management. Open
discussion about mortality can help ease feelings of isolation, depression, and even self-blame
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for treatment failure among patients nearing the end of life (64). Accepting the inevitability of
death as part of the normal human life trajectory, rather than as an enemy to be avoided at all
times, can help re-focus management choices away from options that may no longer be useful or
relevant. A recent study highlights that implantable cardioverter-defibrillators are rarely
deactivated for hospice patients, with many futile and painful shocks in the last months of life
(55). Thresholds for therapeutic curtailment for devices as well as medications should be
established a priori and implemented when appropriate, without drama, guilt, or delay. Often
this requires that physicians and allied caregivers teach patients and families about reasonable
expectations. This requires insight, nuance, language, and end-of-life sophistication to help
patients make well-informed decisions.
Personalized approaches to care may also help contain costs. Many have decried
disproportionate soaring CV healthcare expenditures during the last weeks of life (65,66). More
widespread use and implementation of advance directives, including honoring patients’
expressed wishes, will facilitate appropriate curtailment of aggressive care, including
hospitalization, in patients approaching the end of life. Additionally, alternative approaches to
care, such as home hospital and hospice, should become increasingly accepted by the medical
community and supported by payers as being valid and cost-effective methods for providing
medical care in appropriately selected patients.
Integrating geriatrics into cardiovascular care
While cardiologists have a long tradition of providing outstanding care for CV disorders,
cardiology has not prioritized tools and techniques to manage CV disease as part of a
multisystem approach to care. Cardiologists could learn from geriatricians, i.e., clinicians
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specifically trained to assess different systems in juxtaposition to one another, and to design
management plans that extend across different dimensions of health. Geriatricians also have
better tools to modify care relative to cumulative aging changes, mounting disabilities, and to
consider quality of death as part of standard care. In other words, geriatricians provide a useful
language and process that can be used to augment quality and capacity of cardiac specialists to
meet the needs of their older patients (67).
The American College of Cardiology recently launched a new Council on Cardiovascular
Care for Older Adults. Almost simultaneously, the American Heart Association established a
new committee on Cardiovascular Disease in Older Populations. These steps reflect awareness
of the need to address the aging issue programmatically. Both groups are in their infancy, but
provide opportunity to advance the issues addressed in this document and to facilitate integration
of geriatric cardiology into mainstream CV care.
Research and Education
Research is essential to determine optimal strategies to care for older patients with CVD.
It is critical that clinical datasets include comorbidity, polypharmacy, and frailty in order to
better define the impact of these factors on prognosis and response to therapy. Outcomes must
also be broad, and inclusive of function, quality of life, and iatrogenesis, since these dynamics
are integral to the assessment of therapeutic efficacy.
Today’s expanding arena of clinical datasets at the ACC and throughout the world
provide abundant opportunity to assess the efficacy of diagnosis, risk stratification, and the
impact of specific treatments on relevant clinical outcomes (e.g. quality of life and health status),
and to help refine overall clinical decision-making to optimize older patients’ care and
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outcomes. However, inclusion of functional and health status indices into large registries and
trial databases often remains encumbered by concerns regarding additional costs (who should
pay for exercise assessments?), lack of standardization (how can qualitative measures be as
objective as a mortality endpoint?), and high variance (particularly in regard to functional
measures such as 6 minute walk). Yet in the face of the prominent upsurge in the geriatric
demographic, these methodological challenges must be resolved (68,69); steps to integrate
functional (70) and qualitative measures as standards are essential research goals.
Research can also address the complex relationship between aging and disease such that
CVD in elderly may be prevented by constitutive steps that modulate mechanisms of aging that
predispose to disease. It is fascinating, for example, that caloric restriction may better allay agerelated alterations in left ventricular diastolic filling parameters than pharmacological modalities
(71). Modification of oxidative stress and/or telomere shortening by caloric restriction or other
novel therapies outside the current therapeutic paradigm may prove to be more effective than
conventional medications for moderating morbidity in older CV patients (72).
The aging theme can also be trivialized by studies that do not focus on the real
complexities of age. Whereas many studies claim merit simply on the basis of studying subsets
of older patients, the challenge is to determine if and how less highly selected seniors may be
distinct and if there are fundamentally better healthcare choices and processes for senior patients.
Research must facilitate the tools, skills, systems, and capacities needed to better deal with the
complex older adults who are our real patients.
It is conspicuous that several major cardiovascular syndromes that are relatively
exclusive to older adults (e.g., isolated systolic hypertension, heart failure with preserved
ejection fraction, calcific/degenerative aortic stenosis) (73,74) remain poorly understood and/or
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treated. Improved understanding of the biology of these disorders should lead to opportunities
for new therapies, pharmacological and biological (75), as well as greater appreciation for the
benefits of lifestyle modifications (76). In a related theme, many CV issues that increase in
prevalence with aging often become categorized as primarily CV issues, such that pertinent
geriatric dimensions are overlooked. For example, while atrial fibrillation increases markedly
with age, it is usually managed as a complex CV issue, typically emphasizing
electrophysiological, cardiac, hemodynamic, and vascular parameters. In contrast, age-centric
dimensions of atrial fibrillation care, such as polypharmacology, functional capacity, and
bleeding risks are less routinely stressed.
In view of the crucial need for clinical and basic research on CV disease in the older
population to address its rapidly escalating impact, it is increasingly important to forge
collaborative relationships amongst the key federal institutes such as the National Institutes of
Health, Food and Drug Administration, Center for Medicare Services, Agency for Healthcare
Research and Quality and others as well as non-profit organizations to spawn research that will
better inform clinical decision-making, policy and reimbursement issues.
Linked to these broad clinical and research objectives is a need to disseminate principles
of geriatric cardiology to cardiovascular caregivers and patients so that they are better equipped
to work together in developing a care plan most suited to the patient’s needs and expectations.
Despite an increasingly robust literature focused on geriatric cardiology, it is remarkable that
aging has yet to become a top educational priority for cardiovascular providers. Ironically, there
is no longer a mainstream geriatric cardiology journal in the U.S., in part because publishers are
skeptical that such a journal can be published profitably, yet it is critical that geriatric
perspectives be infused into management of all forms of CVD prevalent in older adults.
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Conclusions
Mainstream cardiology has become, de facto, geriatric cardiology, but it still lacks a
systematic approach that incorporates age-related complexities into routine clinical decisionmaking. The cardiology community must grow and adapt standards of evidence-based care to
older patients, who now constitute the dominant patient population. Cardiology must embrace a
broader paradigm that extends beyond the cardiovascular system, synthesizing multisystem
aging, comorbidities, polypharmacy, psychosocial factors, and personal preferences into an
individualized approach to care. Transitioning to this new paradigm is essential to ensure
provision of optimal care for our older patients with CVD, both for clinical outcomes and patient
satisfaction. A new generation of clinical trials and high-quality observational studies and
registries are essential if we are to refine standards and methods for requisite care. New
approaches and skills geared towards the elderly must be refined and inculcated into routine care
if cardiologists are to preserve a benchmark of excellence and clinical relevance.
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Table: New Paradigm of Care
(1) Emphasize patient-centered approach to care
 Tools to assess CV risk in the context of aggregate age-related risk
o Tools to determine realistic goals in the context of each patient’s overall health
circumstances.
 Incorporate non-cardiac comorbidity, functional capacity, and quality of
life factors into risk/benefit assessment of care options
o Incorporate patient preferences into care plan
 Assessment of end-of-life preferences, including development of advance
directives, designation of durable power of attorney for health care, and (if
appropriate) discussion of palliative care options
 Assess utility of diagnostic testing relative to overall treatment goals
(2) Screen for coexisting geriatric syndromes and comorbidity (e.g. cognitive function,
disability and frailty in patients ≥75 years of age)
 Incorporate standardized geriatric tools (e.g., gait speed, “get up and go” test, MMSE,
etc)
 Screen for depression and/or anxiety
 Screen for caregiver stress, home support
(3) Purposefully manage pharmacological regimen
 Adapt dosing regimen and targets of therapy emphasizing tolerability and affordability
o Weight and renal-adjusted dosing (if appropriate)
o Focus on potential drug-drug and drug-disease interactions
o Assess relative risk and benefit of additional medications
o Utilize services of a geriatric pharmacist (if available)
 Increase vigilance for drug side effects/intolerance
o Enlist assistance of care providers
o Medication reconciliation during all care encounters (particularly following care
transitions)
 Simplify medication regimen if possible (“unprescribe”)
 Provision of tools (e.g. pillboxes, written instructions)
(4) Emphasize the importance of transitions of care
 Improved methods of communications among caregivers and with patients; plan for
collaborative follow up and assessment to prevent gaps or overlaps in care delivery
o Use of nurse clinicians or pharmacists to provide added support
o Clear contact information for all patients when questions arise.
o Transparency in care across providers through more effective utilization of
electronic medical records and traditional methods of correspondence
o Central repository listing all medications, doses, and frequencies
 Patient education designed to promote self-care behaviors and foster adherence to
medicatons, diet, activity recommendations, and other health-promoting behaviors
 Greater utilization of rehabilitation services, including facility-based and home-based
programs, as well as greater utilization of home health services, including home
monitoring
28